Beruflich Dokumente
Kultur Dokumente
Definition:
SUPPLEMENTAL TESTING
Why supplement?
Current methods dont work well Additional information provided by supplemental testing Alternative approaches to current methods
Part One
Inducible resistance
Inducible resistance
I N D U C T I O N I N D U C T I O N
De-repressed or resistant
May be OR
Always
Inducible resistance
Macrolide
Erythromycin Clarithromycin Azithromycin
Lincosamide
Clindamycin Lincomycin
Streptogramin
QuinupristinDalfopristin Pristinamycin
STAPHYLOCOCCI
E R Y T H R O M Y C I N & C L I N D A M Y C I N
Erythromycin S R R
Clindamycin Interpretation S R S Organism susceptible to both Organism resistant to both May have inducible resistance
E R Y T H R O M Y C I N & C L I N D A M Y C I N
E R Y T H R O M Y C I N & C L I N D A M Y C I N
E R Y T H R O M Y C I N & C L I N D A M Y C I N
Inducible resistance
Leclercq R. Mechanisms of Resistance to Macrolides and Lincosamides: Nature of the Resistance Elements and Their Clinical Implications. Clin Infect Dis 2002;34:48292.
E R Y T H R O M Y C I N & C L I N D A M Y C I N
E R Y T H R O M Y C I N & C L I N D A M Y C I N
Other methods
Agar dilution Sensitivity = 91%, specificity = 97% Vitek card Sensitivity = 91%, specificity = 100%
Lavallee, C., et al. (2010). Performance of an Agar Dilution Method and a Vitek 2 Card for Detection of Inducible Clindamycin Resistance in Staphylococcus spp.. J. Clin. Microbiol. 48: 1354-1357
Beta-lactamases
CLASS A: extended-spectrum beta-lactamases CLASS C: ampC beta-lactamases CLASS B: metallo-beta-lactamases
Part Two
BETA-LACTAMASES
Plasmid (acquired)
G E N E A C Q U I S I T I O N
beta-lactamases
ampC
ampC
Chromosomal
A M P C E N Z Y M E S
ampC
Plasmid-mediated Klebsiella spp. Salmonella spp. Proteus mirabilis
A M P C E N Z Y M E S
(E. coli)
CAZ
A M P C E N Z Y M E S A M P C E N Z Y M E S
CAZ
IMP
IMP
ampC inducers
Antibiotic
A M P C E N Z Y M E S A M P C E N Z Y M E S
ampC inhibitors
A M P C E N Z Y M E S
Beta lactam
sulbactam
TEM
E
SHV
clavulanic acid
CTX
B L
tazobactam
usually plasmid-borne
E S B L
E S B L
antibiotic
E S B L
E S B
compete
with the beta-lactamase enzyme
E S B L
2 main methods
Antibiotic interactions Effect of inhibitors
MBL
KPC
Same principle
Substrate Enzyme Inhibitor
ampC
Substrate
imipenem Strong inducer.. but generally not broken down by ampC
Enzyme
Inhibitor
ampC
Substrate
imipenem strong inducer of ampC AND broken down by ampC
ampC
Enzyme Inhibitor cefoxitin (by itself) = small zone (disc) high MIC (dilution)
cefoxitin
Cefta zidime
Cefta zidime
Meropenem
Antibiotic 1
21 mm 21 mm 17 mm
Cefta zidime & Cefta zidime & Meropenem & cl a vulanate cl a vulanate EDTA
Antibiotic 2
27 mm 16 mm 28 mm
Part Three
Interpretation
HETEROGENEOUS POPULATION
Heterogeneous
mostly susceptible
Methicillin resistance
mediated by the mecA gene
M E T H I C I L L I N
(mostly)
Oxacillin (MIC testing only) Cefoxitin (disc testing) Cefoxitin (disc testing)
other methods
detection of pbp2a
latex agglutination kits immunochromatographic kits (Binax)
often seen in: cystic fibrosis, foreign-body infections &osteomyelitis susceptibility may be difficult to test best to use pbp2a or mecA detection
Frank Kipp, Karsten Becker, Georg Peters, and Christof von Eiff. Evaluation of Different Methods To Detect Methicillin Resistance in Small-Colony V ariants of Staphylococcus aureus. J Clin Microbiol. 2004 March; 42(3): 12771279
mecC gene confers resistance to oxacillin and beta-lactams reliably detected by phenotypic methods* not detected by genotypic methods for mecA may show cefoxitin (R), Oxacillin (S) phenotype in Vitek
Skov R, et al. Phenotypic detection of mecC-MRSA: cefoxitin is more reliable than oxacillin. J Antimicrob Chemother . Sep 2013. Cartwright EJP, et al. Use of Vitek 2 antimicrobial susceptibility profile to identify mecC in methicillin-resistant Staphylococcus aureus. J Clin Microbiol 2013;51:27324.
dont have the mecA gene altered pbp (penicillin binding proteins) cefoxitin (S), oxacillin (R) rare phenotype should respond to drugs like augmentin, cephalexin
Massidda, Orietta, et al. Borderline methicillin-susceptible Staphylococcus aureus strains have more in common than reduced susceptibility to penicillinase-resistant penicillins. Antimicrobial Agents and Chemotherapy 40.12 (1996): 2769-2774.
Vancomycin
V A N C O M Y C I N
hVISA:
Laboratory
V A N C O M Y C I N
large molecule, diffuses slowly in agar no disc diffusion criteria for S. aureus resistance to vancomycin: low-level (intermediate-resistance) high-level (vanA mediated) heterogenous (spectrum)
S. aureus isolate with susceptible vancomycin MIC but with proportion of cells with reduced vancomycin susceptibility
Howden, BP., et al. Reduced vancomycin susceptibility in Staphylococcus aureus, including vancomycin-intermediate and heterogeneous vancomycin-intermediate strains: resistance mechanisms, laboratory detection, and clinical implications. Clinical Microbiology Reviews 23.1 (2010): 99-139.
hVISA
V A N C O M Y C I N V A N C O M Y C I N
hVISA
slow growing phenotypic variation MIC = S unstable phenotype
Howden, BP., et al. Reduced vancomycin susceptibility in Staphylococcus aureus, including vancomycin-intermediate and heterogeneous vancomycin-intermediate strains: resistance mechanisms, laboratory detection, and clinical implications. Clinical Microbiology Reviews 23.1 (2010): 99-139.
hVISA
GRD strip
V A N C O M Y C I N
hVISA
Susceptibility
VSSA
Definition
MIC 2 (!) MIC 2 Screening (+) PAP 0.9 MIC 4
Clinical
Laboratory
Potential clinical failure Potential clinical failure Avoid vancomycin Perform screening if risk factors present
Population analysis
VISA / VRSA
Holmes NE, et al. Relationship between vancomycin-resistant Staphylococcus aureus, vancomycin-intermediate S. aureus, high vancomycin MIC, and outcome in serious S. aureus infections. J Clin Microbiol 2012;50:254852.
Traditional way
Tested result Piperacillin -tazobactam Cefotaxime
No Through Road
S R S S
? R R R
Ceftazidime Cefepime
Why?
S R S S
S R S S
Opinion!
Change susceptibility if present inducible clindamycin resistance (blood & bone) Enterobacter spp. and cephalosporin susceptible (blood) Dont know plasmid ampC ESBL KPC MBL (probably dont change tested result)
Conclusions
Standard susceptibility methods work for most organism / antibiotic combinations.
Conclusions
Supplement or MIC alone? (need more clinical evidence)
Its complicated.
Tan Thean Yen